The nurse is caring for a patient who has undergone external ...

[Themember4]

The nurse is caring for a patient who has undergone external fixation of a broken leg and has a cast in place. To prevent skin impairment, the nurse should
 
  a. Not allow the patient to turn in bed because that may lead to redislocation of the leg.
  b. Restrict the patient's dietary intake to reduce the number of times on the bedpan.
  c. Assess all surfaces exposed to the cast for pressure areas.
  d. Keep the patient's blood pressure low to prevent overperfusion of tissue.

Question 2

The nurse assesses the patient's readiness to learn insulin injection sites. Many factors are assessed before teaching. Which of the following factors should the nurse assess first?
 
  a. Previous knowledge level of the patient
  b. Willingness of the patient to learn the injection sites
  c. Financial resources available to the patient for the equipment
  d. Intelligence and developmental level of the patient

[al]

Answer to Question 1

C
Assess all surfaces exposed to casts, cloth restraints, bandages and dressings, tubing, or orthopedic braces. An external device applied to or around the skin exerts pressure or friction on the skin, leading to skin impairment. When restricted from moving, dependent body parts are exposed to pressure that reduces circulation to affected tissues. Know which patients require assistance to turn and change positions. Patients with limited caloric and protein intake develop impaired or delayed wound healing. Keeping the blood pressure artificially low may decrease arterial blood supply, leading to ischemia and breakdown.

Answer to Question 2

B

Feedback
A To determine learning needs, the nurse should assess the patient's previous knowledge level. However, this would not be the most important factor for the nurse to assess first.
B If a person does not want to learn, it is unlikely that learning will occur. Motivation is the first factor the nurse should assess before teaching.
C Assessing a patient's financial resources for obtaining equipment is important; however, it is not the most important factor for the nurse to assess first.
D Assessing the patient's physical and cognitive ability to learn is important. However, it is not the most important factor for the nurse to assess first.

[Themember4]

Gracias!

[hramirez205]

Excellent